Pancreatic adenocarcinoma on top of chronic pancreatitis

Chronic pancreatitis is a known risk factor for pancreatic carcinoma. After 20 years of chronic pancreatitis, there is a 6% cumulative risk of developing pancreatic adenocarcinoma.

DD of this lesion is the inflammatory mass known as mass-forming chronic pancreatitis. However, tumor markers were done for this patient and results were favoring the neoplastic possibility:

• very high CA 19-19-9 measures 490.9 U/ ml/mL (Normal is up to 36 U/ ml/mL)
• high carcinoembryonic antigen measures 5.04 ng/ ml (Normal/mL (normal is up to 3.8 ng/ ml/mL)

The patient was prepared for Whipple operation.

Contributions by Dr. Mohamed Mahmoud Elthokapy

The annotated images highlight the pancreatic mass.

MRI study shows moderate dilatation of the CHD and CBD as well as the intrahepatic biliary radicals and cystic duct. Ballooning of the gall bladder is also noted. The distal end of the CBD is seen ending in a short segment of abrupt caliber change at the ampulla of Vatter impeding the flow of bile into the duodenum with intra-luminalintraluminal signal voids consistent with multiple stones.

Dilated beaded main pancreatic duct measures about 22 mm with associated marked atrophy of the pancreatic parenchyma, dilated side branches of the pancreatic duct giving a "chain of lakes sign", multiple variable-sized signal voidsstones are seen within the main pancreatic duct and its side branches the largest about15 mm.

An ill-defined mass-like lesion is seen involving the pancreatic uncinate process measures about 2 x 2.5 cm, shows mild diffusion restriction with obliterated  surroundingsurrounding fat planes and small regional lymph nodes.